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Study Shows Partners Programs Cut Costs and Reduce Readmission Rates

QIO Report for CMS Demonstrates Success of Community-Based Care Transition Programs

“Impact of a Combined Coleman Care Transitions Interventions® and Bridge Model Intervention on Readmissions and Medicare Spending”

Interventions
The Partners in Care Foundation program combined the Care Transitions Intervention (CTI) Model with the Bridge Patient-Activation Model developed by Rush University in a hybrid social/work-based intervention that could be provided through home visits or telephonically. The focus was on using trained, nonclinical transition coaches to work with patients and their
caregivers on improving patient engagement and empowerment after returning home from the hospital.

Results
The intervention group had significantly lower mortality rates than the comparison group for the entire year after discharge. The intervention group’s all-cause readmission rates were significantly lower up to 60 days after discharge. In addition, the intervention group’s average Medicare spending per beneficiary (MSPB) was significantly lower up to 90 days after discharge.

Conclusions
This social/work-centered, hybrid home and telephonic, patient-centered approach to coaching chronically ill older patients and their caregivers was associated with significant improvements in patient health outcomes (e.g., readmissions and mortality) and reduction in costs after discharge.

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ATTRIBUTION:
Health Services Advisory Group (HSAG), the Medicare Quality Innovation Network
Quality Improvement Organization (QIN-QIO) for California, acting under contract with the Centers for Medicare & Medicaid Services (CMS), grants Partners in Care Foundation
approval to use HSAG-furnished data and analysis contained in this report. HSAG understands Partners in Care may share this information with its partners in this project and may have the intent of submitting all or part of this information for publication.

This material was prepared by Health Services Advisory Group, the Medicare Quality Innovation Network-Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.3-11072018-01

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